Ruby Valley Medical Center

All Charges

Charge

Type

Setting

Price

CARDIAC ARREST TREAT AT SCENE AMBULANCE

Facility

$840.00

Service Code	HCPCS A0999 QN
Hospital Charge Code	600999
Hospital Revenue Code	540
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$840.00
Rate for Payer: Aetna Commercial	$798.00
Rate for Payer: Aetna Medicare	$756.00
Rate for Payer: BCBS MT CHIP	$756.00
Rate for Payer: BCBS MT Closed Plan Network	$798.00
Rate for Payer: BCBS MT HealthLink	$756.00
Rate for Payer: BCBS MT Medicare	$756.00
Rate for Payer: BCBS MT POS	$798.00
Rate for Payer: BCBS MT Traditional	$840.00
Rate for Payer: Cash Price	$756.00
Rate for Payer: Cigna Commercial	$798.00
Rate for Payer: Cigna Medicare	$756.00
Rate for Payer: Medicaid All Medicaid	$772.80
Rate for Payer: Medicare All Medicare	$588.00
Rate for Payer: Monida Allegiance	$798.00
Rate for Payer: Monida First Choice Health	$814.80
Rate for Payer: Monida Montana Health Co-op	$798.00
Rate for Payer: Monida PacificSource	$798.00

CARDIAC ARREST TREAT AT SCENE AMBULANCE

Facility

$840.00

Service Code	HCPCS A0999 QN
Hospital Charge Code	600999
Hospital Revenue Code	540
Min. Negotiated Rate	$588.00
Max. Negotiated Rate	$840.00
Rate for Payer: Aetna Commercial	$798.00
Rate for Payer: Aetna Medicare	$756.00
Rate for Payer: BCBS MT CHIP	$756.00
Rate for Payer: BCBS MT Closed Plan Network	$798.00
Rate for Payer: BCBS MT HealthLink	$756.00
Rate for Payer: BCBS MT Medicare	$756.00
Rate for Payer: BCBS MT POS	$798.00
Rate for Payer: BCBS MT Traditional	$840.00
Rate for Payer: Cash Price	$756.00
Rate for Payer: Cigna Commercial	$798.00
Rate for Payer: Cigna Medicare	$756.00
Rate for Payer: Medicaid All Medicaid	$772.80
Rate for Payer: Medicare All Medicare	$588.00
Rate for Payer: Monida Allegiance	$798.00
Rate for Payer: Monida First Choice Health	$814.80
Rate for Payer: Monida Montana Health Co-op	$798.00
Rate for Payer: Monida PacificSource	$798.00

CARDIOVASCULAR STRESS TEST

Facility

$1,294.00

Service Code	HCPCS 93017
Hospital Charge Code	5193017
Hospital Revenue Code	402
Min. Negotiated Rate	$905.80
Max. Negotiated Rate	$1,294.00
Rate for Payer: Aetna Commercial	$1,229.30
Rate for Payer: Aetna Medicare	$1,164.60
Rate for Payer: BCBS MT CHIP	$1,164.60
Rate for Payer: BCBS MT Closed Plan Network	$1,229.30
Rate for Payer: BCBS MT HealthLink	$1,164.60
Rate for Payer: BCBS MT Medicare	$1,164.60
Rate for Payer: BCBS MT POS	$1,229.30
Rate for Payer: BCBS MT Traditional	$1,294.00
Rate for Payer: Cash Price	$1,164.60
Rate for Payer: Cigna Commercial	$1,229.30
Rate for Payer: Cigna Medicare	$1,164.60
Rate for Payer: Medicaid All Medicaid	$1,190.48
Rate for Payer: Medicare All Medicare	$905.80
Rate for Payer: Monida Allegiance	$1,229.30
Rate for Payer: Monida First Choice Health	$1,255.18
Rate for Payer: Monida Montana Health Co-op	$1,229.30
Rate for Payer: Monida PacificSource	$1,229.30

CARDIOVASCULAR STRESS TEST

Facility

$1,294.00

Service Code	HCPCS 93017
Hospital Charge Code	5193017
Hospital Revenue Code	402
Min. Negotiated Rate	$905.80
Max. Negotiated Rate	$1,294.00
Rate for Payer: Aetna Commercial	$1,229.30
Rate for Payer: Aetna Medicare	$1,164.60
Rate for Payer: BCBS MT CHIP	$1,164.60
Rate for Payer: BCBS MT Closed Plan Network	$1,229.30
Rate for Payer: BCBS MT HealthLink	$1,164.60
Rate for Payer: BCBS MT Medicare	$1,164.60
Rate for Payer: BCBS MT POS	$1,229.30
Rate for Payer: BCBS MT Traditional	$1,294.00
Rate for Payer: Cash Price	$1,164.60
Rate for Payer: Cigna Commercial	$1,229.30
Rate for Payer: Cigna Medicare	$1,164.60
Rate for Payer: Medicaid All Medicaid	$1,190.48
Rate for Payer: Medicare All Medicare	$905.80
Rate for Payer: Monida Allegiance	$1,229.30
Rate for Payer: Monida First Choice Health	$1,255.18
Rate for Payer: Monida Montana Health Co-op	$1,229.30
Rate for Payer: Monida PacificSource	$1,229.30

CARDIOVASCULAR STRESS TEST W/OUT READ

Facility

$74.00

Service Code	HCPCS 93016
Hospital Charge Code	5193016
Hospital Revenue Code	482
Min. Negotiated Rate	$51.80
Max. Negotiated Rate	$74.00
Rate for Payer: Aetna Commercial	$70.30
Rate for Payer: Aetna Medicare	$66.60
Rate for Payer: BCBS MT CHIP	$66.60
Rate for Payer: BCBS MT Closed Plan Network	$70.30
Rate for Payer: BCBS MT HealthLink	$66.60
Rate for Payer: BCBS MT Medicare	$66.60
Rate for Payer: BCBS MT POS	$70.30
Rate for Payer: BCBS MT Traditional	$74.00
Rate for Payer: Cash Price	$66.60
Rate for Payer: Cigna Commercial	$70.30
Rate for Payer: Cigna Medicare	$66.60
Rate for Payer: Medicaid All Medicaid	$68.08
Rate for Payer: Medicare All Medicare	$51.80
Rate for Payer: Monida Allegiance	$70.30
Rate for Payer: Monida First Choice Health	$71.78
Rate for Payer: Monida Montana Health Co-op	$70.30
Rate for Payer: Monida PacificSource	$70.30

CARDIOVASCULAR STRESS TEST W/OUT READ

Facility

$74.00

Service Code	HCPCS 93016
Hospital Charge Code	5193016
Hospital Revenue Code	482
Min. Negotiated Rate	$51.80
Max. Negotiated Rate	$74.00
Rate for Payer: Aetna Commercial	$70.30
Rate for Payer: Aetna Medicare	$66.60
Rate for Payer: BCBS MT CHIP	$66.60
Rate for Payer: BCBS MT Closed Plan Network	$70.30
Rate for Payer: BCBS MT HealthLink	$66.60
Rate for Payer: BCBS MT Medicare	$66.60
Rate for Payer: BCBS MT POS	$70.30
Rate for Payer: BCBS MT Traditional	$74.00
Rate for Payer: Cash Price	$66.60
Rate for Payer: Cigna Commercial	$70.30
Rate for Payer: Cigna Medicare	$66.60
Rate for Payer: Medicaid All Medicaid	$68.08
Rate for Payer: Medicare All Medicare	$51.80
Rate for Payer: Monida Allegiance	$70.30
Rate for Payer: Monida First Choice Health	$71.78
Rate for Payer: Monida Montana Health Co-op	$70.30
Rate for Payer: Monida PacificSource	$70.30

CARPEL TUNNEL SUPP LEFT LG

Facility

$27.00

Hospital Charge Code	2893217
Hospital Revenue Code	290
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

CARPEL TUNNEL SUPP LEFT LG

Facility

$27.00

Hospital Charge Code	2893217
Hospital Revenue Code	290
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

CARPEL TUNNEL SUPP LEFT MED

Facility

$27.00

Hospital Charge Code	2893216
Hospital Revenue Code	290
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

CARPEL TUNNEL SUPP LEFT MED

Facility

$27.00

Hospital Charge Code	2893216
Hospital Revenue Code	290
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

CARPEL TUNNEL SUPP LEFT XLG

Facility

$27.00

Hospital Charge Code	2893218
Hospital Revenue Code	290
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

CARPEL TUNNEL SUPP LEFT XLG

Facility

$27.00

Hospital Charge Code	2893218
Hospital Revenue Code	290
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

CARPEL TUNNEL SUPP R LG

Facility

$27.00

Hospital Charge Code	2893215
Hospital Revenue Code	290
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

CARPEL TUNNEL SUPP R LG

Facility

$27.00

Hospital Charge Code	2893215
Hospital Revenue Code	290
Min. Negotiated Rate	$18.90
Max. Negotiated Rate	$27.00
Rate for Payer: Aetna Commercial	$25.65
Rate for Payer: Aetna Medicare	$24.30
Rate for Payer: BCBS MT CHIP	$24.30
Rate for Payer: BCBS MT Closed Plan Network	$25.65
Rate for Payer: BCBS MT HealthLink	$24.30
Rate for Payer: BCBS MT Medicare	$24.30
Rate for Payer: BCBS MT POS	$25.65
Rate for Payer: BCBS MT Traditional	$27.00
Rate for Payer: Cash Price	$24.30
Rate for Payer: Cigna Commercial	$25.65
Rate for Payer: Cigna Medicare	$24.30
Rate for Payer: Medicaid All Medicaid	$24.84
Rate for Payer: Medicare All Medicare	$18.90
Rate for Payer: Monida Allegiance	$25.65
Rate for Payer: Monida First Choice Health	$26.19
Rate for Payer: Monida Montana Health Co-op	$25.65
Rate for Payer: Monida PacificSource	$25.65

CARPEL TUNNEL SUPP R MED

Facility

$33.00

Hospital Charge Code	2862608
Hospital Revenue Code	270
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: BCBS MT CHIP	$29.70
Rate for Payer: BCBS MT Closed Plan Network	$31.35
Rate for Payer: BCBS MT HealthLink	$29.70
Rate for Payer: BCBS MT Medicare	$29.70
Rate for Payer: BCBS MT POS	$31.35
Rate for Payer: BCBS MT Traditional	$33.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna Commercial	$31.35
Rate for Payer: Cigna Medicare	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

CARPEL TUNNEL SUPP R MED

Facility

$33.00

Hospital Charge Code	2862608
Hospital Revenue Code	270
Min. Negotiated Rate	$23.10
Max. Negotiated Rate	$33.00
Rate for Payer: Aetna Commercial	$31.35
Rate for Payer: Aetna Medicare	$29.70
Rate for Payer: BCBS MT CHIP	$29.70
Rate for Payer: BCBS MT Closed Plan Network	$31.35
Rate for Payer: BCBS MT HealthLink	$29.70
Rate for Payer: BCBS MT Medicare	$29.70
Rate for Payer: BCBS MT POS	$31.35
Rate for Payer: BCBS MT Traditional	$33.00
Rate for Payer: Cash Price	$29.70
Rate for Payer: Cigna Commercial	$31.35
Rate for Payer: Cigna Medicare	$29.70
Rate for Payer: Medicaid All Medicaid	$30.36
Rate for Payer: Medicare All Medicare	$23.10
Rate for Payer: Monida Allegiance	$31.35
Rate for Payer: Monida First Choice Health	$32.01
Rate for Payer: Monida Montana Health Co-op	$31.35
Rate for Payer: Monida PacificSource	$31.35

CARPEL TUNNEL SUPP UNIV LG

Facility

$28.00

Hospital Charge Code	2893219
Hospital Revenue Code	290
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

CARPEL TUNNEL SUPP UNIV LG

Facility

$28.00

Hospital Charge Code	2893219
Hospital Revenue Code	290
Min. Negotiated Rate	$19.60
Max. Negotiated Rate	$28.00
Rate for Payer: Aetna Commercial	$26.60
Rate for Payer: Aetna Medicare	$25.20
Rate for Payer: BCBS MT CHIP	$25.20
Rate for Payer: BCBS MT Closed Plan Network	$26.60
Rate for Payer: BCBS MT HealthLink	$25.20
Rate for Payer: BCBS MT Medicare	$25.20
Rate for Payer: BCBS MT POS	$26.60
Rate for Payer: BCBS MT Traditional	$28.00
Rate for Payer: Cash Price	$25.20
Rate for Payer: Cigna Commercial	$26.60
Rate for Payer: Cigna Medicare	$25.20
Rate for Payer: Medicaid All Medicaid	$25.76
Rate for Payer: Medicare All Medicare	$19.60
Rate for Payer: Monida Allegiance	$26.60
Rate for Payer: Monida First Choice Health	$27.16
Rate for Payer: Monida Montana Health Co-op	$26.60
Rate for Payer: Monida PacificSource	$26.60

CARTRIDGE, TEST CHEM8+ I-STAT (25/BX)

Facility

$214.00

Service Code	HCPCS 80047
Hospital Charge Code	4080047
Hospital Revenue Code	300
Min. Negotiated Rate	$149.80
Max. Negotiated Rate	$214.00
Rate for Payer: Aetna Commercial	$203.30
Rate for Payer: Aetna Medicare	$192.60
Rate for Payer: BCBS MT CHIP	$192.60
Rate for Payer: BCBS MT Closed Plan Network	$203.30
Rate for Payer: BCBS MT HealthLink	$192.60
Rate for Payer: BCBS MT Medicare	$192.60
Rate for Payer: BCBS MT POS	$203.30
Rate for Payer: BCBS MT Traditional	$214.00
Rate for Payer: Cash Price	$192.60
Rate for Payer: Cigna Commercial	$203.30
Rate for Payer: Cigna Medicare	$192.60
Rate for Payer: Medicaid All Medicaid	$196.88
Rate for Payer: Medicare All Medicare	$149.80
Rate for Payer: Monida Allegiance	$203.30
Rate for Payer: Monida First Choice Health	$207.58
Rate for Payer: Monida Montana Health Co-op	$203.30
Rate for Payer: Monida PacificSource	$203.30

CARTRIDGE, TEST CHEM8+ I-STAT (25/BX)

Facility

$214.00

Service Code	HCPCS 80047
Hospital Charge Code	4080047
Hospital Revenue Code	300
Min. Negotiated Rate	$149.80
Max. Negotiated Rate	$214.00
Rate for Payer: Aetna Commercial	$203.30
Rate for Payer: Aetna Medicare	$192.60
Rate for Payer: BCBS MT CHIP	$192.60
Rate for Payer: BCBS MT Closed Plan Network	$203.30
Rate for Payer: BCBS MT HealthLink	$192.60
Rate for Payer: BCBS MT Medicare	$192.60
Rate for Payer: BCBS MT POS	$203.30
Rate for Payer: BCBS MT Traditional	$214.00
Rate for Payer: Cash Price	$192.60
Rate for Payer: Cigna Commercial	$203.30
Rate for Payer: Cigna Medicare	$192.60
Rate for Payer: Medicaid All Medicaid	$196.88
Rate for Payer: Medicare All Medicare	$149.80
Rate for Payer: Monida Allegiance	$203.30
Rate for Payer: Monida First Choice Health	$207.58
Rate for Payer: Monida Montana Health Co-op	$203.30
Rate for Payer: Monida PacificSource	$203.30

CARVEDILOL TAB [12.5 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000070
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

CARVEDILOL TAB [12.5 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000070
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

CARVEDILOL TAB [3.125 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000071
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

CARVEDILOL TAB [3.125 MG]

Facility

$8.00

Service Code	HCPCS J3490
Hospital Charge Code	3000071
Hospital Revenue Code	250
Min. Negotiated Rate	$5.60
Max. Negotiated Rate	$8.00
Rate for Payer: Aetna Commercial	$7.60
Rate for Payer: Aetna Medicare	$7.20
Rate for Payer: BCBS MT CHIP	$7.20
Rate for Payer: BCBS MT Closed Plan Network	$7.60
Rate for Payer: BCBS MT HealthLink	$7.20
Rate for Payer: BCBS MT Medicare	$7.20
Rate for Payer: BCBS MT POS	$7.60
Rate for Payer: BCBS MT Traditional	$8.00
Rate for Payer: Cash Price	$7.20
Rate for Payer: Cigna Commercial	$7.60
Rate for Payer: Cigna Medicare	$7.20
Rate for Payer: Medicaid All Medicaid	$7.36
Rate for Payer: Medicare All Medicare	$5.60
Rate for Payer: Monida Allegiance	$7.60
Rate for Payer: Monida First Choice Health	$7.76
Rate for Payer: Monida Montana Health Co-op	$7.60
Rate for Payer: Monida PacificSource	$7.60

CAST PADDING 3''

Facility

$30.00

Service Code	HCPCS A4590
Hospital Charge Code	80030070
Hospital Revenue Code	270
Min. Negotiated Rate	$21.00
Max. Negotiated Rate	$30.00
Rate for Payer: Aetna Commercial	$28.50
Rate for Payer: Aetna Medicare	$27.00
Rate for Payer: BCBS MT CHIP	$27.00
Rate for Payer: BCBS MT Closed Plan Network	$28.50
Rate for Payer: BCBS MT HealthLink	$27.00
Rate for Payer: BCBS MT Medicare	$27.00
Rate for Payer: BCBS MT POS	$28.50
Rate for Payer: BCBS MT Traditional	$30.00
Rate for Payer: Cash Price	$27.00
Rate for Payer: Cigna Commercial	$28.50
Rate for Payer: Cigna Medicare	$27.00
Rate for Payer: Medicaid All Medicaid	$27.60
Rate for Payer: Medicare All Medicare	$21.00
Rate for Payer: Monida Allegiance	$28.50
Rate for Payer: Monida First Choice Health	$29.10
Rate for Payer: Monida Montana Health Co-op	$28.50
Rate for Payer: Monida PacificSource	$28.50

Know your out-of-pocket cost for care.

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